Correspondence

Secondary attack rate
and superspreading
events for SARS-CoV-2
A basic reproduction number,
R 0, of about 2 was estimated for
severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) in
Wuhan, China, early in the outbreak.1,2
However, this value only captures the
average dynamics of transmission; a
crucial question for control is whether
specific situations and settings
might be driving the outbreak. The
secondary attack rate (SAR), defined
as the probability that an infection
occurs among susceptible people
within a specific group (ie, household
or close contacts), can provide an
indication of how social interactions
relate to transmission risk.
Increasingly, outbreak investigations
are providing insights into the risk of
transmission in different settings.
Drawing on data from nine recent
reports of secondary transmission
associated with a specific event such
as a meal or holiday visit (table), we
estimated 48 secondary infections
occurred among 137 attendees.
Assuming that all these secondary
infections were generated by a single
primary case, which is probable given
the short-term nature of the exposure
events, would imply a SAR among
close contacts of 35% (95% CI 27–44).
If transmission is stratified by
contacts within and outside of
the household, the relationship
between R0 and household risk is:
R 0=SAR HN H + SAR CN C, where SAR H
and SARC are the secondary attack
rates within household and wider
community (ie, outside household),
respectively, and NH and NC are the
numbers of at-risk contacts made,
respectively.3 An infection with a high
household SAR but a modest R0 would
therefore suggest transmission is
driven by a relatively small number of
high-risk contacts. A large household
SAR further suggests that between-
household transmission risk is lower;
otherwise the observed R0 would be
larger.
More data are needed to reliably
estimate the true within-household
and between-household transmission
for SARS-CoV-2; recent reports might
be biased towards larger transmis­
sion events. However, if it transpires
that most at-risk contacts have a
close relationship with cases, and
superspreading events tend to occur at
large gatherings of these close contacts,
measures to reduce infection risk
during such gatherings and subsequent
tracing of close contacts of cases might Published Online
have a disproportionate effect on February 27, 2020
https://doi.org/10.1016/
reducing overall transmission. S0140-6736(20)30462-1
We declare no competing interests.
Yang Liu, Rosalind M Eggo,
*Adam J Kucharski
adam.kucharski@lshtm.ac.uk
Department of Infectious Disease Epidemiology,
London School of Hygiene & Tropical Medicine,
London WC1E 7HT, UK
1 Li Q, Guan X, Wu P, et al. Early transmission
dynamics in Wuhan, China, of novel
coronavirus-infected pneumonia. N Engl J Med
2020; published online Jan 29. DOI:10.1056/
NEJMoa2001316.
2 Riou J, Althaus CL. Pattern of early human-to-
human transmission of Wuhan 2019 novel
coronavirus (2019-nCoV), December 2019 to
January 2020. Euro Surveill 2020; 25: 2000058.
3 Yang Y, Halloran ME, Sugimoto JD, Longini IM.
Detecting human-to-human transmission of
avian influenza A (H5N1). Emerg Infect Dis
2007; 13: 9.

Date of Setting Number at Subsequently

exposure gathering infected
(excluding
primary case)
Harbin, Heilongjiang, Jan 24, 2020 Meal (home) 8 8
China
Shuangyashan, Jan 24, 2020 Meal (home) 13 4
Heilongjiang, China
Hangzhou, Zhejiang, Jan 17, 2020 Meal (unknown location) 1 1
China
Nanjing, Jiangsu, China Jan 23, 2020 Meal (unknown location) 8 7
Nanjing, Jiangsu, China Jan 24, 2020 Meal (restaurant) 14 3
Enshi, Hubei, China Unknown Meal (unknown location) 17 2
Enshi, Hubei, China Unknown Meal (unknown location) 47 10
Haute-Savoie, France Jan 24–28, 2020 Chalet 11 5
Hong Kong Unknown Meal (home) 18 8
See Online for appendix
Full details are provided in the appendix.
Submissions should be
Table: Summary of severe acute respiratory syndrome coronavirus 2 transmission events where the made via our electronic
submission system at
numbers of people exposed and subsequently infected were known, assuming a single primary
http://ees.elsevier.com/
case, by location
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